ACJ injury Myths Debunked

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Acromioclavicular Joint injuries - the myths and facts

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  • 1. AC Joint InjuriesThree MythsDebunked!Lennard Funklenfunk@shoulderdoc.co.uk@theshoulderdoc

2. Type 1 Type 2 Type 3Type 4 Type 5 Type 6NormalRockwood ClassificationFractures in Adults, 1991 3. Arthroscopy. Feb, 2013.there is a general consensus for nonoperativetreatment of Rockwood type I and type II lesions,initial nonsurgical treatment of type III lesions,and operative intervention for Rockwood type IVto VI lesions 4. Case 1: Would you Fix this?A. YesB. NoC. Abstain 5. Case 2: Would you Fix this?A. YesB. NoC. Abstain 6. The extent to which beliefsare based on evidenceis very much lessthan believers supposeBertrand RussellThe Skeptical Essays, 1928 7. Myth 1.Treat according to GradeThe Grade does not matter 8. Indications for StabilisationLiterature = Type 4, 5 & 6 9. Inter-Observer Reliability: Rockwood classification Mean inter-observer agreement = 64.6% Weighted kappa = 0.258 Tossy and Allman classification Mean inter-observer agreement = 68.1% Weighted kappa = 0.309Intra-Observer Reliability: Rockwood classification Mean inter-observer agreement = 59.4% Weighted kappa = 0.150 Tossy and Allman classification Mean inter-observer agreement = 67.4% Weighted kappa = 0.113The classification of AC joint injuries using radiographsalone has limited reliability and consistencyin clinical practice. 10. The Rockwood classificationsystem has limitedinterobserver andintraobserver reliability,even with the help of 3D CT.Inconsistent agreement withuse of this system limits itsrole in clinical decision-making.201423:665-70 11. Clinical Grade? 12. Clinical Grade? 13. Instability? 14. Case 13 monthsPain free FROM 15. Case 23 monthsPainful ++ 16. Myth 2.The clavicle is displacedIt is a Scapula Injury 17. SICK ScapulaScapular malpositionInferior medial border prominenceCoracoid pain & malpositiondysKinesis of scapularGumina et al.Arthroscopy. 200970.6% of patients exhibited scapular dyskinesis58.3% met criteria for SICK scapular syndromePatients with dyskinesis = lower Constant &Simple Shoulder Scores 18. Locked Scapula (stable) 19. Shocked Scapula (unstable) 20. Myth 3.Reconstruct the CC LigamentsIts not just about theCoracoclavicular Ligaments 21. CoracoclavicularLigamentsHarris et. al. Am J Sports Med. 2000Strength 500N (+/- 134)Stiffness 103N/mm (+/- 30)Uniaxial Tension 25mm/min 22. ACJ LigamentsTwo thirds of the superiorstability for lesser displacements90% the posterior stabilityFukuda et al. JBJSA. 1986 23. Dynamic StabilityDelto-trapezial fasciaFukuda et al. JBJSA. 1986:Copeland & Kessel. Injury. 1980;DePalma. 1973;Urist. JBJS 1963.Lizaur et al. JBJS. 1994Many unsatisfactory results could be due to lackof repair of the trapezius and deltoid. 24. Harris et al. AJSM 2000None of the reconstruction techniques analyzed inthe present study were able to restore the normalmechanical function of the intact coracoclavicularligament complex 25. My Approach:Scapula Injury:Separation of the Axial And Appendicular segmentsLook for:Locked ScapulaShocked Scapula Dont make decisions on X-Rays or scansDont be hasty to operateReview:CoperNon-coper 26. My indicationsPatient DemandsWork demandsSociety demandsOverhead Athlete 27. ManagementAcute Injury< 1 weekScapula RehabReview3 weeksCoping Not CopingScapula RehabReview3 months Surgery 28. Nottingham ApproachShoulderdoc.co.uk 29. Standard repairShoulderdoc.co.uk 30. Modification 1 (2008)Shoulderdoc.co.uk 31. Modification 2Shoulderdoc.co.uk 32. ClosureRepair the Superior AC LigamentsRepair the Delto-Trapezial Fascia 33. KSSTA, 2014 34. KSSTA, 2014 35. THANK YOUThe extent to which beliefsare based on evidenceis very much lessthan believers supposelenfunk@shoulderdoc.co.ukBertrand Russell@theshoulderdoc